British Journal of Anaesthesia 1995; 75: 369–377 Malignant hyperthermia and compartment syndrome

Sir,—We were interested to read the report by O’Donnell and colleagues [1] of a patient with compartment syndrome occurring as a complication of malignant hyperthermia (MH). We recently managed a similar case. A 29-yr-old, previously healthy man presented for repair of a fractured tibial plateau. After induction of anaesthesia with propofol, midazolam and fentanyl, he was allowed to breathe isoflurane and 66 % nitrous oxide in oxygen. After 1.5 h he developed stridor which persisted despite attempts to manipulate the laryngeal mask airway. He was then given suxamethonium which resulted in the rapid onset of masseter and generalized muscle spasm. His temperature, measured nasally, increased rapidly to 40.3 C, arterial PCO2 reached 12.1 kPa and he developed a metabolic acidosis with a base deficit of 12.3 mmol litre 1. Serum potassium was 6.8 mmol litre 1 and creatinine kinase increased to greater than 190 000. Despite the severity of this fulminant attack of MH, the patient made a rapid response to dantrolene (total dose 5.5 mg kg 1). Within a few hours his metabolic derangement was corrected and his trachea was extubated on the following morning. Over the next 12 h he developed marked swelling of his right forearm, right calf and foot. This was associated with restricted movement, pain exacerbated by passive extension and decreased sensation to light touch. A diagnosis of compartment syndrome was made and he underwent fasciotomies to the relevant muscle compartments under general anaesthesia using propofol, fentanyl and atracurium. This and subsequent anaesthetics for wound closure were uncomplicated and the patient made a full recovery with no loss of function in either limb. With greater awareness among anaesthetists and the availability of dantrolene, patients with fulminant MH are much more likely to survive than previously [2]. Such patients are at risk of developing compartment syndrome and we emphasize the importance of clinical signs in the early diagnosis of this potentially serious complication of MH. When indicated, fasciotomy should be performed and we suggest that the risk of anaesthesia after recovery from fulminant MH is small, and not sufficient to justify avoiding surgery. A. P. H. STEELE M. M. IMRIE A. M. RUTHERFORD W. N. BRADLEY St Peter’s Hospital Chertsey Surrey